Event Notification Report for April 19, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/16/2021 - 04/19/2021
Agreement State
Event Number: 55186
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee:
Region: 3
City: Duluth State: MN
County:
License #: 1048
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Ossy Font
Notification Date: 04/09/2021
Notification Time: 16:08 [ET]
Event Date: 04/01/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/09/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
PELKE, PATRICIA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 4/19/2021
EN Revision Text: AGREEMENT STATE REPORT - DOSE ADMINISTERED GREATER THAN PRESCRIBED
The following was received from the Minnesota Department of Health via email:
"A medical event has occurred at Essentia Health, Duluth, MN (MN license number 1048). The event occurred on April 1, 2021 and was discovered by the radiation safety officer on April 8, 2021. The licensee reported the event to the state of Minnesota on April 8, 2021.
"Preliminary details are as follows: A Y-90 Theraspheres procedures with a prescribed dose of 140 Gy administered 173.4 Gy on April 1, 2021. This resulted in a dose [that varied by] greater than 20 percent of prescribed. The event was discovered by the radiation safety officer following a records review and reported to the state of Minnesota within 24 hours of discovery. The licensee is investigating the root cause and the potential for harm to the patient. A report will be submitted within 15 days.
"The state plans to do an on-site investigation with the licensee. Additional information will be reported following the final report from the licensee and investigation by the state."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Agreement State
Event Number: 55189
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Element Hotel
Region: 4
City: Superior State: CO
County:
License #: GL002594
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Notification Date: 04/12/2021
Notification Time: 18:23 [ET]
Event Date: 12/11/2020
Event Time: 00:00 [MDT]
Last Update Date: 04/12/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
PICK, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 4/19/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITUM EXIT SIGNS
The following synopsis was received from the Colorado Department of Public Health and Environment via email:
During an inventory, a hotel manager discovered two exit signs were lost, each containing 7.62 Ci of tritium.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf